Endoscopic endonasal transplanum transtuberculum approach for retrochiasmatic craniopharyngiomas: Operative nuances

Abstract

The surgical treatment of craniopharyngiomas is challenging. An optimal surgical approach is extremely important to achieve complete removal of the tumor, which is often the goal of treatment. Conventionally, the endoscopic transsphenoidal approach is used for resection of craniopharyngiomas that are essentially confined to the sellar cavity, or have smaller suprasellar extension. However, the tumors located in the retrochiasmatic space are difficult to remove surgically due to a poor access. Traditionally, various transcranial microsurgical routes have been employed with limited success for resection of retrochiasmatic craniopharyngiomas. The transcranial approaches generally do not provide adequate exposure of the tumors originating in the space under the optic chiasm and nerves. Recently, the extended endonasal endoscopic surgical route, obtained by removal of the tuberculum sellae and planum sphenoidale, has been used with great success in the surgical management of tumors lying ventral to the optic chiasm, including craniopharyngiomas. It offers a direct midline access to the retrochiasmatic space and provides excellent visualization of the undersurface of the optic chiasm. It also allows extracapsular dissection using binostril-bimanual technique and facilitates complete removal of these formidable tumors. In this report, we describe step-by-step, the technical details of the endonasal endoscopic transplanum transtuberculum approach with emphasis on the operative nuances for removal of retrochiasmatic craniopharyngiomas.

Defining the lateral limits of the endoscopic endonasal transtuberculum transplanum approach: anatomical study with pertinent quantitative analysis

“…he extended endoscopic endonasal transtuberculum transplanum approach has been claimed, over the past decades, to be a versatile route for accessing the suprasellar area. [2][3][4]10,11,21,24,39,45,[48][49][50] Despite initial doubts related to the possibility of safely accessing neurovascular structures and pathologies via the nose, this technique has been widely accepted for the treatment of select midline anterior skull base lesions, such as craniopharyngiomas and/or meningiomas, after it was determined that this approach is effective and safe. 12,13,17,20,22,23,30,31,[35][36][37]40,42,46,53 Nevertheless, one of the major limitations of the endoscopic endonasal approach concerns the possibility of accessing the lateral aspects of the planum sphenoidale.…”

Extended Endoscopic Endonasal Transplanum and Transdorsum Sellar Approach for the Resection of Retroinfundibular Craniopharyngioma With Two-Piece Dural Opening: A Technical Case Report

“…For posterior clinoidectomy and dorsum sellae resection, we used an angled endoscope (30-degree endoscope). It provides a direct "looking-up" visualization and allows for a wider surgical space for the drilling of PCPs from the bottom to the top [ 8 , 15 , 16 ].…”

Sellar, suprasellar, and parasellar masses: Imaging features and neurosurgical approaches

“…In addition to the bony resection of the sellar face, the tuberculum selle and posterior planum sphenoidale are also removed. 94 The optic canals serve as the lateral limits and the posterior ethmoidal arteries mark the anterior limits of this approach. 94 The dura is often incised at the midline to avoid injury to the optic nerves and supraclinoid carotid artery; the superior intercavernous sinus may need to be ligated.…”

“…Indications for the TT/TP EEA include suprasellar lesions such as tuberculum meningiomas, craniopharyngiomas, and select intrasellar lesions with significant suprasellar extension. 94,95 The suprasellar region can be easily accessed via transcranial approaches as well (see below), and there are ongoing efforts to determine which lesions are best suited for the TT/TP EEA. For example, some have reported favorable outcomes using the TT/TP EEA for craniopharyngiomas [96][97][98][99] and the transcranial approach may be superior for patients with planum and tuberculum meningiomas.…”

“…94 The optic canals serve as the lateral limits and the posterior ethmoidal arteries mark the anterior limits of this approach. 94 The dura is often incised at the midline to avoid injury to the optic nerves and supraclinoid carotid artery; the superior intercavernous sinus may need to be ligated. Suprasellar lesions are typically debulked prior to extracapsular dissection to allow for visualization of the following critical structures: optic nerves, supraclinoid carotid artery, superior hypophyseal artery, anterior cerebral artery complex, and the pituitary stalk.…”